Choosing Wisely

Campaign by American Board of Internal Medicine to challenge medical societies to identify 5 tests, procedures, or treatments within each specialty offered to patients despite an absence of benefit, or in some cases, despite evidence demonstrating disutility or harm.

Medical specialty societies are engaged in trying to identify and discourage practices that are not evidence-based or have the potential to cause unwanted outcomes.

Unnecessary and inappropriate tests harm patients by causing them anxiety, discomfort, increase numbers of irrelevant and incidental findings, and expose patients to ionizing radiation that have harmful effects.

At least 27% of investigations that are ordered on admission to the hospital are avoidable, and it increases to 63% on subsequent days.

There are more than 500 recommendations from 80 medical societies on record.

Choosing wisely” concludes that the evidence is insufficient to support routine use of annual general health check ups for asymptomatic adults without a specific concern, chronic condition, or evidence-based prevention strategy.

As much as 30% of US healthcare spending are for interventions with marginal clinical benefit.

Many diagnostic tests are unnecessary and may lead to an appropriate treatment or a cascade of additional tests or procedures.

Estimated $30 billion is wasted annually on unnecessary imaging tests in the US.

Reasons for over-testing: belief ordering many tests will help detectct sub clinical disease, defensive medicine, lack of confidence or knowledge, patient ‘s expect ions, and profit.

Institute of Medicine estimates that was one of three dollars spent on healthcare is wasted and the diagnostic testing is particularly inefficient.

Imaging is by far the most common service on the list of unnecessary tests and procedures such that 20-50% of imaging is unnecessary (Hendee WR et al).

Unnecessary diagnostic imaging remains a substantial problem with the United States occupying top usage ranks, with population rates of annual CT scans of 245 per 1000 people, and magnetic resonance imaging scans 118 per 1000 people that are five and three times higher than in those of other countries, respectively.

IOM estimates that $750 billion could be saved annually by reducing healthcare inefficiencies, including $210 billion by eliminating unnecessary services.

Reducing unneeded investigations can decrease costs and in many cases increase patients satisfaction and quality of care.

Recommendations include avoiding liberal red blood cell transfusions.

Utilizing a restrictive threshold of 7-8 g/dL of hemoglobin for transfusion in the vast majority of stable, hospitalized patients without evidence of inadequate tissue oxygenation.

Avoiding thrombophilia testing in adults in the setting of transient major thrombosis risk factors.

Avoiding inferior cava filter usage except in specified circumstances.

Avoiding the use of plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists.

There is no evidence to support screening for vitamin D deficiency in average risk individuals.

American Society for Radiation Oncology (ASTRO) suggested equivalent pain relief for metastatic bone metastases in prostate cancer following 30 Gy 10 fractions, 20 Gy right fractions, and a single 8 Gy fraction.

Limiting routine CT scan surveillance after curative treatment of non-Hodgkin’s lymphoma.

It is recommended that imaging for uncomplicated headaches be limited.

Imaging for uncomplicated headache is not recommended.

EEGs should not be done to evaluate headaches, as it has a zero net benefit.

The American Association of Neurology recommends not to prescribe interferon-beta or glatiramer acetate to patients with disability from progressive, with disability from progressive, non-relapsing forms of multiple sclerosis.

American Society of Oncology recommends the avoidance of routine use of staging imaging in patients with early stage breast cancer with no clinical findings to suggest the presence of metastatic spread.

It is recommended not to use computed tomography, PET scans, or radionuclide bone scans for patients with breast or prostate cancer at low risk for metastasis.

Radiographic incidentalomas, defined as abnormalities that did not serve as the primary reason for the performance of the test are very common.

Incidentalomas have major financial and health consequences, further wasted efforts for unnecessary diagnosis and treatment and patient anxiety.

Patients with urinary catheters should not be screened or treated for asymptomatic bactiuria.

Patients with asymptomatic bactiuria should not be treated with antibiotics.

Imaging is not recommended for patients with uncomplicated headache.

Annual ECGs or other cardiac screening is not recommended for patients with low risk disease without symptoms.

Stress cardiac imaging or advanced noninvasive imaging is not recommended as the initial evaluation of patients without cardiac symptoms unless high risk markers are present.

Stress cardiac imaging or advanced noninvasive imaging is not recommended as a preoperative assessment in patients scheduled to undergo low risk noncardiac surgery.

ECG is not recommended in follow-up for mild, asymptomatic native valve disease in adults with no change signs or symptoms.

It is not necessary screen exercise ECG testing in individuals who are asymptomatic and at low risk for coronary heart disease.

It is not necessary for stress cardiac imaging or coronary angiography in patients without cardiac symptoms, unless high risk markers are present.

Cardiac imaging is not necessary for patients who are at low risk.

It is not necessary to obtain a preoperative chest x-ray in the absence of a clinical suspicion for intrathoracic disease.

Physicians should avoid admission for preoperative chest x-rays for ambulatory patients with unremarkable history and physical examination.

It is not necessary for imaging of low back pain patients within the first 6 weeks of symptoms, unless red flags are present.

Antibiotics should not be routinely prescribed for patients with acute mild-moderate sinusitis unless symptoms last 7 days or more, or worsen after initial clinical improvement.

Nonsteroidal anti-inflammatory drug should be avoided in individuals with hypertension, heart failure, or chronic kidney disease of all causes, including diabetes.

Screening women less than 30 years of age for cervical cancer with HPV testing is not recommended.

In stage 1A non-small cell lung cancer brain imaging is not indicated, in the absence of neurologic findings.

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